AOA Council on Palliatve CareGoals of Care

AOA Council on Palliatve CareGoals of Care

Breaking Bad NewsBreaking Bad NewsUnity ConventionUnity Convention

October 24, 2010October 24, 2010

Bruce Bates, D.O., FACOFP, CMDBruce Bates, D.O., FACOFP, CMD

Chair - Department of Geriatric MedicineChair - Department of Geriatric Medicine

University of New England College of Osteopathic MedicineUniversity of New England College of Osteopathic Medicine

Breaking Bad NewsBreaking Bad NewsUnity ConventionUnity Convention

October 24, 2010October 24, 2010

Bruce Bates, D.O., FACOFP, CMDBruce Bates, D.O., FACOFP, CMD

Chair - Department of Geriatric MedicineChair - Department of Geriatric Medicine

University of New England College of Osteopathic MedicineUniversity of New England College of Osteopathic Medicine

Case Case

84 y/o W/F living independently, falls 84 y/o W/F living independently, falls at home suffering L femur Fxat home suffering L femur Fx

Undergoes ORIF with post op Undergoes ORIF with post op delerium, dysphagia, renal failure.delerium, dysphagia, renal failure.

Aspirates, intubated difficult to weanAspirates, intubated difficult to wean

Attentive daughterAttentive daughter

84 y/o W/F living independently, falls 84 y/o W/F living independently, falls at home suffering L femur Fxat home suffering L femur Fx

Undergoes ORIF with post op Undergoes ORIF with post op delerium, dysphagia, renal failure.delerium, dysphagia, renal failure.

Aspirates, intubated difficult to weanAspirates, intubated difficult to wean

Attentive daughterAttentive daughter

Case continuedCase continued Day #14 – many doctors talk to Day #14 – many doctors talk to

daughterdaughter

Nephrologist: making more urine but Nephrologist: making more urine but probably will need dialysis long termprobably will need dialysis long term

Intensivist: able to turn O2 down to 50%Intensivist: able to turn O2 down to 50%

Gastroenterologist: plan for a PEG will Gastroenterologist: plan for a PEG will never eat regularnever eat regular

Internist – not doing wellInternist – not doing well

Case manager – doctor ordered hospiceCase manager – doctor ordered hospice

Daughter calls PCP to complainDaughter calls PCP to complain

Day #14 – many doctors talk to Day #14 – many doctors talk to daughterdaughter

Nephrologist: making more urine but Nephrologist: making more urine but probably will need dialysis long termprobably will need dialysis long term

Intensivist: able to turn O2 down to 50%Intensivist: able to turn O2 down to 50%

Gastroenterologist: plan for a PEG will Gastroenterologist: plan for a PEG will never eat regularnever eat regular

Internist – not doing wellInternist – not doing well

Case manager – doctor ordered hospiceCase manager – doctor ordered hospice

Daughter calls PCP to complainDaughter calls PCP to complain

Objectives . . .Objectives . . . Know why defining goals fo care is Know why defining goals fo care is

importantimportant

Understand a 7-step protocol for Understand a 7-step protocol for delivering bad newsdelivering bad news

Communicate uncertainty and conflict Communicate uncertainty and conflict

Adjust care to changing goalsAdjust care to changing goals

Know why defining goals fo care is Know why defining goals fo care is importantimportant

Understand a 7-step protocol for Understand a 7-step protocol for delivering bad newsdelivering bad news

Communicate uncertainty and conflict Communicate uncertainty and conflict

Adjust care to changing goalsAdjust care to changing goals

Most people want to Know if facing a Most people want to Know if facing a serious illnessserious illness

Strengthens the physician- patient Strengthens the physician- patient relationshiprelationship

Fosters collaborationFosters collaboration

Establishes an appropriate allocation of Establishes an appropriate allocation of resourcesresources

Permits patients, families to plan, copePermits patients, families to plan, cope

Most people want to Know if facing a Most people want to Know if facing a serious illnessserious illness

Strengthens the physician- patient Strengthens the physician- patient relationshiprelationship

Fosters collaborationFosters collaboration

Establishes an appropriate allocation of Establishes an appropriate allocation of resourcesresources

Permits patients, families to plan, copePermits patients, families to plan, cope

Importance of Goals of CareImportance of Goals of Care

Potential goals of carePotential goals of care

Cure of diseaseCure of disease

Avoidance of Avoidance of premature death premature death

Maintenance or Maintenance or improvement in improvement in functionfunction

Prolongation of lifeProlongation of life

Cure of diseaseCure of disease

Avoidance of Avoidance of premature death premature death

Maintenance or Maintenance or improvement in improvement in functionfunction

Prolongation of lifeProlongation of life

Relief of sufferingRelief of suffering

Quality of lifeQuality of life

Staying in controlStaying in control

A good death A good death

Support for Support for families and loved families and loved onesones

Relief of sufferingRelief of suffering

Quality of lifeQuality of life

Staying in controlStaying in control

A good death A good death

Support for Support for families and loved families and loved onesones

Osteopathic TenetOsteopathic Tenet

THE WHOLE PERSONTHE WHOLE PERSON

BODYBODY

MINDMIND

SPIRITSPIRIT

THE WHOLE PERSONTHE WHOLE PERSON

BODYBODY

MINDMIND

SPIRITSPIRIT

Multiple goals of careMultiple goals of care

Multiple goals often apply Multiple goals often apply simultaneouslysimultaneously

Goals are often contradictoryGoals are often contradictory

Certain goals may take priority over Certain goals may take priority over othersothers

Multiple goals often apply Multiple goals often apply simultaneouslysimultaneously

Goals are often contradictoryGoals are often contradictory

Certain goals may take priority over Certain goals may take priority over othersothers

Patient Centered CarePatient Centered Care

Goals of Patient - initial assessmentGoals of Patient - initial assessment

May Vary over time - ongoing May Vary over time - ongoing assessmentassessment

curative curative palliative palliative

self self family family

physical physical spiritual spiritual

integrated integrated focused focused

Goals of Patient - initial assessmentGoals of Patient - initial assessment

May Vary over time - ongoing May Vary over time - ongoing assessmentassessment

curative curative palliative palliative

self self family family

physical physical spiritual spiritual

integrated integrated focused focused

Goals may changeGoals may change

Osteopathic Principles make very clear Osteopathic Principles make very clear the distinction of caring for disease and the distinction of caring for disease and caring for the patient who has diseasecaring for the patient who has disease

Some goals take precedence over othersSome goals take precedence over others

The shift in focus of careThe shift in focus of care

Requires the patient (Guardian) to understand Requires the patient (Guardian) to understand

is gradualis gradual

is an expected part of the continuum of is an expected part of the continuum of medical caremedical care

Osteopathic Principles make very clear Osteopathic Principles make very clear the distinction of caring for disease and the distinction of caring for disease and caring for the patient who has diseasecaring for the patient who has disease

Some goals take precedence over othersSome goals take precedence over others

The shift in focus of careThe shift in focus of care

Requires the patient (Guardian) to understand Requires the patient (Guardian) to understand

is gradualis gradual

is an expected part of the continuum of is an expected part of the continuum of medical caremedical care

7-step protocol to communicate bad news . . .7-step protocol to communicate bad news . . .

1.1. Create the right setting Create the right setting

2.2. Determine what the patient and Determine what the patient and family knowfamily know

3.3. What do they want to Know What do they want to Know

1.1. Create the right setting Create the right setting

2.2. Determine what the patient and Determine what the patient and family knowfamily know

3.3. What do they want to Know What do they want to Know

. . . 7-step protocol to negotiate goals of care. . . 7-step protocol to negotiate goals of care

4. 4. Sharing the informationSharing the information

5.5. Respond with empathy Respond with empathy

6.6. Make a plan and follow-through Make a plan and follow-through

7.7. Review and revise periodically, as Review and revise periodically, as appropriateappropriate

4. 4. Sharing the informationSharing the information

5.5. Respond with empathy Respond with empathy

6.6. Make a plan and follow-through Make a plan and follow-through

7.7. Review and revise periodically, as Review and revise periodically, as appropriateappropriate

1. Create the Right Setting

1. Create the Right Setting

Quiet - private spaceQuiet - private space

Allot enough open ended timeAllot enough open ended time

Determine that the right people are Determine that the right people are presentpresent

FAMILY CLERGY GUARDIAN OTHERFAMILY CLERGY GUARDIAN OTHER

Quiet - private spaceQuiet - private space

Allot enough open ended timeAllot enough open ended time

Determine that the right people are Determine that the right people are presentpresent

FAMILY CLERGY GUARDIAN OTHERFAMILY CLERGY GUARDIAN OTHER

2. What Does the Patient Know

2. What Does the Patient Know

Establish Patients Knowledge and Establish Patients Knowledge and UnderstandingUnderstanding

Asses ability to comprehendAsses ability to comprehend

Correct misunderstandingCorrect misunderstanding

Reschedule if unprepared or Reschedule if unprepared or unresolvable conflict of infounresolvable conflict of info

Establish Patients Knowledge and Establish Patients Knowledge and UnderstandingUnderstanding

Asses ability to comprehendAsses ability to comprehend

Correct misunderstandingCorrect misunderstanding

Reschedule if unprepared or Reschedule if unprepared or unresolvable conflict of infounresolvable conflict of info

3. How Much Does the Patient Want to Know3. How Much Does the Patient Want to Know Recognize patient preferencesRecognize patient preferences

May decline voluntarilyMay decline voluntarily

May designate someone to May designate someone to communicate on his/her behalfcommunicate on his/her behalf

Consider Power of Attorney or advanced Consider Power of Attorney or advanced directive – 5 wishesdirective – 5 wishes

Recognize patient preferencesRecognize patient preferences

May decline voluntarilyMay decline voluntarily

May designate someone to May designate someone to communicate on his/her behalfcommunicate on his/her behalf

Consider Power of Attorney or advanced Consider Power of Attorney or advanced directive – 5 wishesdirective – 5 wishes

3. How much does the patient want to know?3. How much does the patient want to know? People handle information differentlyPeople handle information differently

CapacityCapacity

RaceRace

Ethnicity Ethnicity

ReligionReligion

EducationEducation

Socio economicSocio economic

Age and developmental levelAge and developmental level

People handle information differentlyPeople handle information differently

CapacityCapacity

RaceRace

Ethnicity Ethnicity

ReligionReligion

EducationEducation

Socio economicSocio economic

Age and developmental levelAge and developmental level

Cultural differencesCultural differences

Who gets the information?Who gets the information?

How to talk about information?How to talk about information?

Who makes decisions?Who makes decisions?

Ask the patientAsk the patient

Consider a family meetingConsider a family meeting

Who gets the information?Who gets the information?

How to talk about information?How to talk about information?

Who makes decisions?Who makes decisions?

Ask the patientAsk the patient

Consider a family meetingConsider a family meeting

4. Sharing the Information4. Sharing the Information Say it then STOPSay it then STOP

Avoid monologue- promote dialogueAvoid monologue- promote dialogue

Avoid Jargon and EuphemismsAvoid Jargon and Euphemisms

Pause frequentlyPause frequently

Validate understandingValidate understanding

Use Silence and Body LanguageUse Silence and Body Language

Don’t minimize severityDon’t minimize severity

Implications of “I’m Sorry”Implications of “I’m Sorry”

Say it then STOPSay it then STOP

Avoid monologue- promote dialogueAvoid monologue- promote dialogue

Avoid Jargon and EuphemismsAvoid Jargon and Euphemisms

Pause frequentlyPause frequently

Validate understandingValidate understanding

Use Silence and Body LanguageUse Silence and Body Language

Don’t minimize severityDon’t minimize severity

Implications of “I’m Sorry”Implications of “I’m Sorry”

Language with unintended consequences -NegativeLanguage with unintended consequences -Negative Do you want us to do everything Do you want us to do everything

possible?possible?

Will you agree to discontinue care?Will you agree to discontinue care?

It’s time we talk about pulling backIt’s time we talk about pulling back

I think we should stop aggressive I think we should stop aggressive therapytherapy

I’m going to make it so he won’t sufferI’m going to make it so he won’t suffer

Do you want us to do everything Do you want us to do everything possible?possible?

Will you agree to discontinue care?Will you agree to discontinue care?

It’s time we talk about pulling backIt’s time we talk about pulling back

I think we should stop aggressive I think we should stop aggressive therapytherapy

I’m going to make it so he won’t sufferI’m going to make it so he won’t suffer

Language to describethe goals of care - positive . .

Language to describethe goals of care - positive . . I want to seek the most comfort and I want to seek the most comfort and

dignity possible until the day you diedignity possible until the day you die

We will concentrate on improving the We will concentrate on improving the quality of your child’s remaining lifequality of your child’s remaining life

Let’s discuss your needs and wantsLet’s discuss your needs and wants

I want to seek the most comfort and I want to seek the most comfort and dignity possible until the day you diedignity possible until the day you die

We will concentrate on improving the We will concentrate on improving the quality of your child’s remaining lifequality of your child’s remaining life

Let’s discuss your needs and wantsLet’s discuss your needs and wants

5. Respond with Empathy5. Respond with Empathy Affective responseAffective response

Tears anger sadness love anxiety reliefTears anger sadness love anxiety relief

Cognitive responseCognitive response

Denial blame guilt disbelief fear loss Denial blame guilt disbelief fear loss shameshame

Basic psychophysiologic responseBasic psychophysiologic response

Fight – FlightFight – Flight

Affective responseAffective response

Tears anger sadness love anxiety reliefTears anger sadness love anxiety relief

Cognitive responseCognitive response

Denial blame guilt disbelief fear loss Denial blame guilt disbelief fear loss shameshame

Basic psychophysiologic responseBasic psychophysiologic response

Fight – FlightFight – Flight

5. Respond with Empathy5. Respond with Empathy

Listen Listen ListenListen Listen Listen

Encourage descriptions of FeelingsEncourage descriptions of Feelings

Use Non Verbal communicationUse Non Verbal communication

Physician: Acknowledge YurselfPhysician: Acknowledge Yurself

Listen Listen ListenListen Listen Listen

Encourage descriptions of FeelingsEncourage descriptions of Feelings

Use Non Verbal communicationUse Non Verbal communication

Physician: Acknowledge YurselfPhysician: Acknowledge Yurself

6. Planning and followup6. Planning and followup

Explore what their hopes Explore what their hopes expectations and Fears areexpectations and Fears are

Plan for Next StepsPlan for Next Steps

Added tests, treatment/non treatment,Added tests, treatment/non treatment,

Care vs cure, referralsCare vs cure, referrals

Sources of Support for patient/familySources of Support for patient/family

Medical, spiritual, emotional, social, Medical, spiritual, emotional, social, legallegal

Explore what their hopes Explore what their hopes expectations and Fears areexpectations and Fears are

Plan for Next StepsPlan for Next Steps

Added tests, treatment/non treatment,Added tests, treatment/non treatment,

Care vs cure, referralsCare vs cure, referrals

Sources of Support for patient/familySources of Support for patient/family

Medical, spiritual, emotional, social, Medical, spiritual, emotional, social, legallegal

7. Review and Revise 7. Review and Revise

Give Contact info / next appointmentGive Contact info / next appointment

Assess Safety Assess Safety

Assess informal and formal supportAssess informal and formal support

Be Prepared to repeat info at next Be Prepared to repeat info at next visit – it was not all heardvisit – it was not all heard

Goals Change with time and Goals Change with time and progression of conditionprogression of condition

Give Contact info / next appointmentGive Contact info / next appointment

Assess Safety Assess Safety

Assess informal and formal supportAssess informal and formal support

Be Prepared to repeat info at next Be Prepared to repeat info at next visit – it was not all heardvisit – it was not all heard

Goals Change with time and Goals Change with time and progression of conditionprogression of condition

Reviewing goals,treatment prioritiesReviewing goals,treatment priorities Goals guide care – whose?Goals guide care – whose?

Assess priorities to develop initial Assess priorities to develop initial plan of careplan of care

Review with any change inReview with any change in

health statushealth status

advancing illnessadvancing illness

setting of caresetting of care

treatment preferencestreatment preferences

Goals guide care – whose?Goals guide care – whose?

Assess priorities to develop initial Assess priorities to develop initial plan of careplan of care

Review with any change inReview with any change in

health statushealth status

advancing illnessadvancing illness

setting of caresetting of care

treatment preferencestreatment preferences

Communicating prognosisCommunicating prognosis Providers markedly over-estimate Providers markedly over-estimate

prognosisprognosis

Either way raises fears and stressesEither way raises fears and stresses

Helps patient / family cope, planHelps patient / family cope, plan

increase access to hospice, other increase access to hospice, other servicesservices

Offer a range or average for life Offer a range or average for life expectancyexpectancy

Providers markedly over-estimate Providers markedly over-estimate prognosisprognosis

Either way raises fears and stressesEither way raises fears and stresses

Helps patient / family cope, planHelps patient / family cope, plan

increase access to hospice, other increase access to hospice, other servicesservices

Offer a range or average for life Offer a range or average for life expectancyexpectancy

Truth-telling and maintaining hopeTruth-telling and maintaining hope False hope may deflect from other False hope may deflect from other

important issuesimportant issues

True clinical skill to help find hope True clinical skill to help find hope for realistic goalsfor realistic goals

False hope may deflect from other False hope may deflect from other important issuesimportant issues

True clinical skill to help find hope True clinical skill to help find hope for realistic goalsfor realistic goals

When Family Says:“Don’t Tell”

When Family Says:“Don’t Tell”

Ask Family Ask Family

Why not? What are you afraid I will say?Why not? What are you afraid I will say?

What are previous experiences?What are previous experiences?

Personal,religious, or cultural context?Personal,religious, or cultural context?

Patient knows something - why this Patient knows something - why this conspiracy? Will it feed mistrust?conspiracy? Will it feed mistrust?

Talk To patient togetherTalk To patient together

Legal Obligation to obtain consent to Legal Obligation to obtain consent to treat or not treat (assuming capacity)treat or not treat (assuming capacity)

Ask Family Ask Family

Why not? What are you afraid I will say?Why not? What are you afraid I will say?

What are previous experiences?What are previous experiences?

Personal,religious, or cultural context?Personal,religious, or cultural context?

Patient knows something - why this Patient knows something - why this conspiracy? Will it feed mistrust?conspiracy? Will it feed mistrust?

Talk To patient togetherTalk To patient together

Legal Obligation to obtain consent to Legal Obligation to obtain consent to treat or not treat (assuming capacity)treat or not treat (assuming capacity)

Determine specific prioritiesDetermine specific priorities Based on Patient values, Based on Patient values,

preferences, clinical circumstancespreferences, clinical circumstances

Influenced by information from Influenced by information from physician(s), team members, Patient physician(s), team members, Patient and familyand family

Clinical JazzClinical Jazz

Based on Patient values, Based on Patient values, preferences, clinical circumstancespreferences, clinical circumstances

Influenced by information from Influenced by information from physician(s), team members, Patient physician(s), team members, Patient and familyand family

Clinical JazzClinical Jazz

SummarySummary Begin the conversation EarlyBegin the conversation Early

Keep seven steps in mindKeep seven steps in mind

Understand the Goal of CareUnderstand the Goal of Care

Patient centered values and preferencesPatient centered values and preferences

Seek permission to involve family and Seek permission to involve family and othersothers

Give Permission to react/accept/rejectGive Permission to react/accept/reject

Revise and renewRevise and renew

Begin the conversation EarlyBegin the conversation Early

Keep seven steps in mindKeep seven steps in mind

Understand the Goal of CareUnderstand the Goal of Care

Patient centered values and preferencesPatient centered values and preferences

Seek permission to involve family and Seek permission to involve family and othersothers

Give Permission to react/accept/rejectGive Permission to react/accept/reject

Revise and renewRevise and renew

IATPIATP

IT’s ABOUT IT’s ABOUT THE PATIENTTHE PATIENTIT’s ABOUT IT’s ABOUT

THE PATIENTTHE PATIENT